.jpg)
Starting 40, the female body changes significantly under the influence of hormones. Ongoing injuries, stiffness, lack of energy, mental issues, and increased body weight can seriously affect their performancein CrossFit. It is important to understand the possible causes and know the three- pillar treatment. CrossFit coaches need to support these women.
CrossFit makes you feel sore, many times. And that is ok, sometimes even a bit addictive😉 But there is a difference between feeling sore after a workout versus ongoing aches, pains, stiffness, injuries and a lack of energy. These are often-heard symptoms of women entering their forties and can seriously hinder their performance during a WOD. It can also leave them feeling frustrated, insecure, or anxious because their body does not act, respond, and recover like it used to. What does not help either is that many women do not talk about it, for several reasons, as we discussed in our previous article on Hormones and vague symptoms. Such as because of the vagueness of the symptoms; the idea that talking about it is the synonym for being a nagger; or because of a lack of acknowledgement by health professionals (Tanko et al. 2005).
It is important to understand the possible causes of the symptoms of these women, and be aware of the fact that in many cases treatment is easily available and staying active is crucial. In this article we describe one of the main causes of these symptoms and the associated three-pillar treatment. We also address the role and responsibility of CrossFit coaches in supporting women to cope with the symptoms while staying active.
Ageing, exercise and injuries
Ageing causes “structural and functional alterations in the human body, rendering elderly people [we like to call them masters] liable to overloading of the musculoskeletal and cardiovascular systems. It should, however, be kept in mind that immobilisation and inactivity have even more deleterious effects on structures and functions in [masters] than in younger adults.” (Kallinen & Markku, 1995)
Physically active masters are capable to even further improve their health. They can even start CrossFit at an older age as we explained in our article Can you start CrossFit at an older age? However, they will be “affected by some of the drawbacks of physical overloading, mostly due to the diminished ability of aging body systems to adapt to high levels of loading. […] Muscle has been reported to be the most commonly acutely injured tissue among active [master]. The lower extremities are the most susceptible to injury. In treating injuries in [masters], it is most important to avoid the detrimental effects of immobilisation; this requires active treatment and rehabilitation with compensatory exercise therapy.” (Kallinen & Markku, 1995)
“The best 'treatment' for sports-related injuries is prevention. Good agility, technical skills, and cardiovascular and musculoskeletal fitness are important in injury prevention among [masters]. Appropriate training programmes, the use of safe and familiar equipment, careful warming up and cooling down, multiphasic training [including the training of neurophysiological functions (balance, coordination and reaction time)] and muscle strength are essential aspects of injury prevention.” (Kallinen & Markku, 1995)
In other words: CrossFit.
Female ageing process
As women age, let’s say from the age of forty, the concentration of estrogen and other female hormones decline. This hormonal decrease has been associated with a number of negative outcomes, including a greater incidence of injury as well as a delay in recovery from these injuries (Enns & Tiidus, 2010).
Common physical and mental struggles of women entering their forties are headaches, sleeping disorders, tiredness, depressed moods and leaking urine (Berecki-Gisolf et al, 2009; Brown et al, 2002).
One of the most severe complaints in women approaching menopause is musculoskeletal pain that affects bones, joints, ligaments, tendons and or muscles. The increase in the prevalence and incidence of osteoarthritis (a form of arthritis that occurs when the protective cartilage that cushions the ends of the bones wears down over time and commonly affects joints in hands, knees, hips and spinal cord (Mayo Clinic,2021), among women after the menopause, also draws attention to the possible contribution of estrogen deficiency (Berecki-Gisolfet al, 2009; Brown et al, 2002; Lu et al, 2020; Szoeke et al, 2005; Tankó etal, 2005)
Women experiencing these symptoms report significantly lower levels of health- related quality of life and significantly higher health care utilization than women without menopausal symptoms (Whiteley et al, 2013).
Three pillar treatment
Studies demonstrate that effective treatment of (musculoskeletal) menopausal symptoms has three pillars: 1) Hormone Replacement Therapy; 2) High intensity strength training with dietary adjustments, and 3) Active coping strategies.
1. Hormone Replacement Therapy
Studies show that estrogen seems to have protective effects against various types of injury and disease states and inflammation. It also has an antioxidant capacity that plays a role in cardiac muscle, and it seems to play a significant role in stimulating muscle repair and regenerative processes. Females with normal levels of female hormones have lower creatine kinase activity after exercise compared with males. Creatine kinase is an indirect marker of muscle damage. Furthermore, studies show that estrogen seems to attenuate neuropathic pain [an often chronic shooting or burning pain as a result of nerve damage or malfunctioning nervous system (WebMD, 2021)], and inflammation that is developed after spinal cord injury.
Although the protective role of estrogen especially on skeletal muscles is not fully understood, evidence is often based on post menopausal women, and evidence is more clear in animals than in humans, Hormone Replacement Therapy seems to counter the negative effects of the hormonal decrease on osteoarthritis/ musculoskeletal issues. Especially estrogen combined with exercise seems to limit muscle damage and inflammation and stimulate repair (Enns & Tiidus, 2010; Kendall & Eston, 2002; Lee et al, 2018; Tankó et al, 2005; Tiidus, 2000).
2. High intensity strength training with dietary adjustments
High intensity strength training in a dynamic form that exceeds the threshold and is done regularly and consistent combined with a) a sufficient calorie intake (meaning: eat enough calories); b) an adequate intake of calcium and vitamin D3*; and c) an adequate intake of protein (The importance of strength training and protein after 30) helps to slow down the process of ageing and specifically of sarcopenia and osteoporosis: The inevitable loss of muscle mass and bone density, related to hormonal decrease. Low intensity exercise, often seen among women of a certain age, and insufficient dietary adjustments often explain lack of results (Borer, 2005).
Furthermore, certain nutritional interventions such as avoiding sugar, pre-prepped food, alcohol and caffeine, hot spices, and trans fats, can contribute to a better hormonal balance and less menopausal symptoms. Tackle menopausal symptoms with food.
Hormone Replacement Therapy, high intensity strength training and dietary adjustments also contribute to maintaining a healthy weight, and that helps to mute menopausal symptoms and improve pain and joint function (Mayo Clinic, 2021). A weight gain of 2 to 3 kg during the menopause is normal, but more than that is unnecessary.
According to The Dutch Health Council the adequate daily intake of calcium for women of 25 years and older is 1 gram with a max of 2,5 grams per day. Dairy is a good source of calcium and also some forms of grains and green veggies. Vitamin D stimulates the uptake of calcium. Coffee, alcohol, grains and spinach hinder the uptake. The adequate daily intake of vitamin D for women of 25 years and older is 10 microgram per day and 20 micrograms for women over 70. Fatty fish is a good source of vitamin D (Voedingscentrum, 2021).
3. Active coping strategies
Hormonal changes are natural events in life, although menopause is often described as a period of physical and emotional changes that affect the lifestyle of women in multiple ways. The many different way these changes are experienced by women is influenced by their personal, family and sociocultural background.
Studies have shown that health care professionals pay little attention to women´s perceptions regarding menopause, while “personal and tailored healthcare according to individual needs, preferences and expectations should be provided, considering the vulnerability most of these women experience.” (Hoga et al, 2015).
Regardless of the support by health professionals, it is important for women to be prepared of what might be coming. This means being able to cope with the unpredictability and fluctuations of the physical and emotional changes and menopausal symptoms. It is about so much more than just dealing with a hot flash at night. The changes can affect women’s perception of their feminine identity and their self-worth. It can impact personal relations, careers and the quality of life (Yazdkhasti et al, 2019).
Women tend to use passive coping mechanisms to deal with stressful events, when in fact this leads to even more stress and more experienced menopausal symptoms. Active coping mechanisms are far more effective.
Active and passive coping
“Active coping [or approach- coping/ problem- focused coping] refers to cognitive and behavioral attempts to deal directly with problems and their effects (Choi et al, 2012). The focus is on changing the stressful situation.” Active coping means you are convinced you can influence or control the stressful situation.
Aspects of active coping methods are positive emotions and the use of positive words (The importance of positive words in CrossFit), finding benefits of meaning, engaging in emotional approach by expressing how you feel, and accommodating to the stressor by learning how to deal with it and move on (Sarafino & Smith, 2016).
“Passive coping [or avoidant- coping/ emotion- focused coping] refers to cognitive attempts to avoid actively confronting problems and/or behaviors to indirectly reduce emotional tension by such behaviors as eating or smoking more (Billings & Moos, 1981, p.141).” Also behavior such as meditation and avoidance to get through the situation are considered passive coping. “Passive coping responses are often used when individuals decide that the basic circumstances cannot be altered and, thus, they need to accept a situation as it is (Blalock &Joiner, 2000).” (Choi et al, 2012)
Passive coping mechanisms, often used by women, are not effective. They lead to more stress and unhealthy behavior compared to active coping strategies. Study has shown that this maladaptive coping mediates the effects of menopausal symptoms and the associated poorer quality of life (Ngai et al, 2019).
The way we handle stress, our coping strategies, are often part of our upbringing, but coping strategies can also change during our lives. The most effective coping strategy is the one that neutralizes one’s perception of the stressor (the cause of the stress) and decreases the risk of a future stressful event.
Active coping strategies can be developed. For example by enhancing social support; managing interpersonal problems by being assertive and consider situations as a challenge instead of a threat; investing in time- management by setting goals and developing plans to reach those goals; preparing for stressful events; and living a healthy lifestyle (Sarafino & Smith, 2016).
Pychosocial aspects related to active coping, such as “optimism, emotional stability, emotion regulation, self-compassion, and self-esteem are strongly related to women's well-being and mental health in perimenopause, in terms of higher life satisfaction, lower perceived stress, lower psychological distress, better general psychological health; milder menopausal complaints and lower depressive symptoms.” (Suss et al, 2021).
Key in active coping strategies is to increase personal control and sense of coherence (Ngai, 2019; Sarafino & Smith, 2016). “Sense of coherence reflects a coping capacity of people to deal with every day life stressors and consists of three elements: comprehensibility, manageability and meaningfulness.“. One of the underlying mechanisms of sense of coherence is empowerment (Super et al, 2016).
Empowerment
Empowerment is defined as “a process through which people gain greater control over decisions and actions affecting their health” and should be seen as both an individual and a community process. Fundamental to empowerment are being aware of the fact that women are in control of their life, health and well-being; knowledge about, in this case menopausal symptoms and how it can affect one’s life; skills to handle the situation and the consequences; and a facilitating environment that encourages and supports women (WHO, 2009).
Studies have shown that empowerment has positive effects on menopausal women and will even guarantee their health. Empowerment programs, such as the application of the concept of Positive Health in coaching, as done by CrossFit Eudokia, can contribute to improving the perception of this stage and the importance of self-care (Yazdkhasti et al, 2015; 2019).
Furthermore, effective coping strategies are creative and dynamic: What worked before might not work right now anymore, and what works for the one does not necessarily work for the other. Acknowledgement and consideration of complex issues that are relevant at that particular time in life, are key (Hoga et al, 2015).
The role and responsibility of CrossFit coaches
(Most) CrossFit coaches are not health care professionals, though they can be considered as health professionals who see their clients far more frequent than health care professionals. This, and the fact that menopausal symptoms can strongly affect women’s performance during a WOD, gives them the responsibility to be aware of the health status of clients. CrossFit is about improving the quality of life, regardless of age, impairment, or fitness.
Knowledge
Since CrossFit is for everyone, everyone can be a client. This implies CrossFit coaches need at least some basic knowledge of the physical and mental changes related to different phases in life and to the process of ageing. For example, they need to pay special attention to athletic women who have been exercising excessively at a young age. Disorders of bone density are especially prevalent among these women, due to a decreased rate of bone accretion in youth often as a result of hormonal deficiency and/or excessive exercise. It predisposes them to stress-related bone injuries and increases the risk of osteoporosis and insufficiency fractures with aging (MacKnight, 2017).
Awareness
CrossFit coaches don’t need to make medical diagnoses, but they do need to be aware of certain signs in women in their forties (and on), in relation to their performance in a WOD, injuries and their health. They need to be able to recognize certain signs, just as they recognize a no- rep in an air squat.
Coaching is a two- way street and listening to what clients are saying but also what they are not saying is at least as important as talking. CrossFit coaches are in the unique position to get topics that should be talked about but are often left in the dark, out in the open. This asks for certain skills.
Empower
CrossFit coaches have the amazing position to empower women and to create a facilitating environment to enhance a sense of coherence. They can share knowledge and create awareness, since many women don’t even know that what they are dealing with are menopausal symptoms, how menopause relates to injuries or how it effects their performance. By talking about it and encouraging women to take matters into their hands, for example by seeing a health care professional to get treatment, they can empower these women.
Furthermore, using positive words in CrossFit, as mentioned above, helps to strengthen women’s sense of coherence. That also contributes to the development of a positive (growth) mindset which is strongly related to active coping mechanisms (Do you have the right mindset?).
CrossFit coaches need to take women with menopausal symptoms serious and act in respond to it. Not by ignoring them out of ignorance; not by putting them away as naggers; or telling them to suck it up, work harder or sleep it off. It is about teaching clients how to take care of their bodies, how to take their health into their own hands, how to train smarter and not harder, and how to stay active while dealing with physical and mental changes.
Because CrossFit is about increasing work capacity across broad times and modal domains, throughout life!
Create your own health!©
References (in alphabetical order)
Berecki-Gisolf J, Begum N, Dobson AJ. Symptoms reported by women in midlife: menopausal transition or aging? Menopause. 2009Sep-Oct;16(5):1021-9. doi: 10.1097/gme.0b013e3181a8c49f. PMID: 19546824.
Borer KT. Physical activity in the prevention and amelioration of osteoporosis in women :interaction of mechanical, hormonal and dietary factors. Sports Med.2005;35(9):779-830. doi: 10.2165/00007256-200535090-00004. PMID: 16138787.
Brown WJ, Mishra GD, Dobson A. Changes in physical symptoms during the menopause transition. Int J Behav Med.2002;9(1):53-67. doi: 10.1207/s15327558ijbm0901_04. PMID: 12112996.
Choi, N. G., Hegel, M. T.,Sirrianni, L., Marinucci, M. L., & Bruce, M. L. (2012). Passive coping response to depressive symptoms among low-income homebound older adults: doesit affect depression severity and treatment outcome?. Behaviour research and therapy, 50(11), 668–674.
Enns DL, Tiidus PM. The influence of estrogen on skeletal muscle: sex matters. Sports Med. 2010 Jan1;40(1):41-58. doi: 10.2165/11319760-000000000-00000. PMID: 20020786.
Hoga L, Rodolpho J, Gonçalves B, Quirino B. Women's experience of menopause: a systematic review of qualitative evidence. JBI Database System Rev Implement Rep. 2015 Sep 16;13(8):250-337.doi: 10.11124/jbisrir-2015-1948. PMID: 26455946.
https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925. Accessed September 2021.
https://www.voedingscentrum.nl/encyclopedie/calcium.aspx. Accessed September 2021
https://www.voedingscentrum.nl/encyclopedie/vitamine-d.aspx. Accessed September 2021
https://www.webmd.com/pain-management/guide/neuropathic-pain .Accessed September 2021
Kendall B, Eston R. Exercise-induced muscle damage and the potential protective role ofestrogen. Sports Med. 2002;32(2):103-23. doi: 10.2165/00007256-200232020-00003.PMID: 11817996.
Kallinen M, Markku A. Aging, physical activity and sports injuries. An overview of common sports injuries in the elderly. Sports Med. 1995 Jul;20(1):41-52. doi:10.2165/00007256-199520010-00004. PMID: 7481278.
Lee JY, Choi HY, Ju BG, Yune TY. Estrogen alleviates neuropathic pain induced after spinal cord injury by inhibiting microglia and astrocyte activation. Biochim Biophys Acta Mol Basis Dis. 2018 Jul;1864(7):2472-2480. doi:10.1016/j.bbadis.2018.04.006. Epub 2018 Apr 16. PMID: 29653184.
Lu CB, Liu PF, Zhou YS, Meng FC, Qiao TY, YangXJ, Li XY, Xue Q, Xu H, Liu Y, Han Y, Zhang Y. Musculoskeletal Pain during theMenopausal Transition: A Systematic Review and Meta-Analysis. Neural Plast.2020 Nov 25;2020:8842110. doi: 10.1155/2020/8842110. PMID: 33299396; PMCID:PMC7710408.
MacKnight JM. Osteopenia and Osteoporosis in Female Athletes. Clin Sports Med. 2017 Oct;36(4):687-702. doi:10.1016/j.csm.2017.05.006. PMID: 28886822.
Ngai FW. Relationships between menopausal symptoms, sense of coherence, coping strategies, and quality of life. Menopause. 2019 Jul;26(7):758-764. doi: 10.1097/GME.0000000000001299.PMID: 30649086.
Sarafino, Edward P., Smith, TimothyW. (2016). Health Psychology: Biopsychosocial interactions, 9th Edition.
Super, S., Wagemakers, M.A.E., Picavet,H. S. J., Verkooijen, K. T., Koelen, M. A. Strengthening sense of coherence: opportunities for theory building in health promotion, Health Promotion International, Volume 31, Issue 4, December 2016, Pages 869–878,
Süss H, Willi J, Grub J, Ehlert U. Psychosocial factors promoting resilience during the menopausal transition. Arch Womens Ment Health. 2021 Apr;24(2):231-241. doi:10.1007/s00737-020-01055-7. Epub 2020 Jul 27. PMID: 32719937; PMCID: PMC7979610.
Szoeke CE, Cicuttini F, Guthrie J, DennersteinL. Self-reported arthritis and the menopause. Climacteric. 2005 Mar;8(1):49-55.doi: 10.1080/13697130400012296. PMID: 15804731.
Tankó LB, Karsdal MA, Christiansen C. The clinical potential of estrogen for the prevention of osteoarthritis: what is known and what needs to be done? Womens Health (Lond). 2005Jul;1(1):125-32. doi: 10.2217/17455057.1.1.125. PMID: 19803953.
Tiidus PM. Estrogen and gender effects on muscle damage, inflammation, and oxidative stress. Can J Appl Physiol. 2000 Aug;25(4):274-87. doi: 10.1139/h00-022. PMID:10953066.
Whiteley J, DiBonaventura Md, Wagner JS, AlvirJ, Shah S. The impact of menopausal symptoms on quality of life, productivity,and economic outcomes. J Womens Health (Larchmt). 2013 Nov;22(11):983-90. doi:10.1089/jwh.2012.3719. Epub 2013 Oct 1. PMID: 24083674; PMCID: PMC3820128.
WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care.Geneva: World Health Organization; 2009. 2, Patient empowerment and health care. Available from: https://www.ncbi.nlm.nih.gov/books/NBK144022/
Yazdkhasti M, Negarandeh R, Behboodi Moghadam Z. An empowerment model of Iranian women for the management of menopause: a grounded theory study. Int J Qual Stud Health Well-being. 2019Dec;14(1):1665958. doi: 10.1080/17482631.2019.1665958. PMID: 31589094; PMCID:PMC6792047.
Yazdkhasti M, Simbar M, Abdi F. Empowerment and coping strategies in menopause women: a review. Iran Red CrescentMed J. 2015 Mar 20;17(3):e18944. doi: 10.5812/ircmj.18944. PMID: 26019897;PMCID: PMC4441783.
